|Year : 2018 | Volume
| Issue : 1 | Page : 9-14
Interdisciplinary investigation of occurrence of diverticular disease among patients referred for barium enema and colonoscopy studies at Dr. George Mukhari Academic Hospital, Ga-Rankuwa, Pretoria, South Africa
John Osi Ozoh1, Moinuddeen Vally2, Olakunle A Towobola3
1 Department of Diagnostic Radiology, Sefako Makgatho Health Sciences University, Ga-Rankuwa, Pretoria, South Africa
2 Department of General Surgery, Sefako Makgatho Health Sciences University, Ga-Rankuwa, Pretoria, South Africa
3 Department of Internal Medicine, Sefako Makgatho Health Sciences University, Ga-Rankuwa, Pretoria, South Africa
|Date of Web Publication||2-Jan-2018|
John Osi Ozoh
Department of Diagnostic Radiology, Sefako Makgatho Health Sciences University, P.O. Box 63, MEDUNSA, 0204, Ga-Rankuwa, Pretoria
Background: Diverticular disease (DD) is believed to be a disease which is prevalent in developed countries. Contrary to this belief, DD has been reported with an increasing trend in prevalence in Africa for the past four decades. Objectives: The objective of this study was to highlight the increasing trend of DD and to corroborate barium enema findings obtained from Diagnostic Radiology Department, with colonoscopy results from the Surgery Department at Dr. George Mukhari Academic Hospital. Methods: Results for barium enema and colonoscopy investigations of all the patients referred over a 1-year period were retrospectively reviewed by two independent research groups; each of these groups was unaware of the research carried out in the Departments of Diagnostic Radiology and Surgery. Data from the records were analyzed with the Statistical Package for the Social Sciences (IBM SPSS, version 22.0), New York, USA, version 22.0. Results: Barium enema results of 166 patients were evaluated for DD, and out of these, 129 patients (77.7%) were negative, while 37 patients (22.3%) (95% confidence interval = 19.07–25.50) were positive. A review of 384 colonoscopy results also revealed positive evidence for 47 patients (13.5%) (95% confidence interval = 10.30–17.50) for DD and 337 patients (86.5%) were negative. The findings of barium enema and colonoscopy investigative studies were similar for female preponderance, diffuse pattern of distribution of DD and the mean age of patients. Conclusion: The two studies corroborate each other and have produced the highest number of diagnostic yield for DD in one year, in Africa.
Keywords: Barium enema, colonoscopy, diverticular disease, prevalence, South Africa
|How to cite this article:|
Ozoh JO, Vally M, Towobola OA. Interdisciplinary investigation of occurrence of diverticular disease among patients referred for barium enema and colonoscopy studies at Dr. George Mukhari Academic Hospital, Ga-Rankuwa, Pretoria, South Africa. West Afr J Radiol 2018;25:9-14
|How to cite this URL:|
Ozoh JO, Vally M, Towobola OA. Interdisciplinary investigation of occurrence of diverticular disease among patients referred for barium enema and colonoscopy studies at Dr. George Mukhari Academic Hospital, Ga-Rankuwa, Pretoria, South Africa. West Afr J Radiol [serial online] 2018 [cited 2018 Jul 19];25:9-14. Available from: http://www.wajradiology.org/text.asp?2018/25/1/9/221918
| Introduction|| |
Diverticular disease (DD) is believed to be dominant in developed countries. The risk factors of this disease are advancing age, abnormal colonic motility, intake of low-fiber diet, and urbanization.,,,, Vally et al. reported that the pathogenesis of the disease is possibly due to lifestyle factors. Thus, most of the cases have been reported from developed countries. However, since 1994, at the advent of a new democratic dispensation in South Africa, there has been considerable migration of people from rural settings into urban areas. The migration pattern, especially among the South Africans of African descent, seems to have led to dramatic changes in their diet. The traditional African diet which is naturally high in fiber and known to be protective against DD  would have given actively refined diets low in dietary fiber. Due to this, similar changes in diet would manifest in an upward trajectory in the prevalence of DD among black South Africans.
The aim of this study is to highlight the increasing trend of DD among South Africans as determined from results of two investigative modalities, namely barium enema from the Diagnostic Radiology Department and colonoscopy from the general surgery department. From the two different methods of barium enema and colonoscopy, this study was able to determine the prevalence of DD, the pattern of distribution, and the presenting symptoms. The most common presenting symptom was previously shown to be lower gastrointestinal bleeding., The location of the DD has been reported to be of a diffuse pattern,,,, but other studies in Africa have reported the preponderance of the disease on the right side, findings which correspond to what were reported in studies involving Asian population.,,,
Several authors in recent years have reported a higher incidence of DD among female patients;, also, majority of the studies conducted within the last two decades reported male preponderance regarding the incidence of DD. The mean age of 60 years and above for the presentation of DD has been documented by many authors – there is a clear indication of the fact that the incidence of this disease increases with advancing age.,,,
No single case of DD was recorded in 2367 autopsies and 600 barium enema investigations performed at Chris Hani Baragwanath Academic Hospital, Soweto, South Africa, over a 2-year period from 1954 to 1956. DD of the colon is common in developed countries; however, it is by no means rare in Africa as demonstrated by the increasing trend of this disease.,,,
| Methods|| |
The medical records and results of all patients who were referred to the Radiology Department for barium enema and those who underwent colonoscopy in the general surgery department over a period of 1 year were retrospectively reviewed in each of the two departments. In Diagnostic Radiology Department, the results of 166 patients above the age of 18 years referred for barium enema studies, from June 1, 2014, to May 31, 2015, were reviewed for DD by two radiologists. Multi Diagnost Eleva Philips Digital Fluoroscopy machine was used for barium enema studies. Standard radiological operational procedure, which includes fasting after midnight, special diet a day before the examination (water, tea or coffee without milk, or clear liquid), and taking a laxative a night before the examination, was used. Barium enema images were easily retrieved for evaluation from the in-built, internal storage facility of the fluoroscopic machine.
All the medical records and results of 384 South African patients of African descent above the age of 18 years referred for colonoscopy at the endoscopy suite of Surgery department, from January 1, to December 31, 2015, were evaluated for DD. Standard colonoscopy operational procedure was employed and this includes signing of informed consent, light diet a day before the examination, as well as taking a laxative a night before the studies.
Ethical clearance was given separately for the barium enema study (Certificate SMUREC/M/282/2015:IR) And ethical clearance for colonoscopy and colonoscopy (SMUREC/M/63/2016: PG) was given by the Sefako Makgatho Health Sciences University Research Ethics Committee. Permission to utilize information from patients' records for the purpose of this paper was also granted by the Chief Executive Officer of Dr. George Mukhari Academic Hospital (DGMAH).
Data from the two modalities of investigations were subjected to descriptive statistics which described the characteristics of the patients and percentages of the variables necessary for the study objectives. All analyses of the variables from the records of the two studies were analyzed using the Statistical Package for the Social Sciences (SPSS, version 22.0) software program. Evidence of statistical significant difference between the two studies was noted if P ≤ 0.05.
| Results|| |
The present study reports on independent diagnostic procedures of 384 colonoscopies and 166 barium enema. Out of these numbers, 47 cases of DD were diagnosed by colonoscopy while 37 cases were diagnosed by barium enema. The point prevalence of DD calculated for each of the two methods was 13.5% (95% confidence interval = 10.30–17.50) for colonoscopy method and 22.3% (95% confidence interval = 19.07–25.50). Although there is an apparent difference in the two prevalence values, this did not translate to a statistical significant difference (P = 0.9522). The mean age (±standard deviation) of the patients was 63.0 years (±15.6) for barium enema and 67.4 years (±9.6) for colonoscopy, with no statistical difference in patients' ages in the two methods (P = 0.1414). Patients ≥60 years were consistently more in each of the two methods of diagnosis and the group of patients older than 60 years was statistically similar for both methods (P = 0.9421) [Table 1].
There were more females among patients diagnosed by barium enema (62.2%) and this compares with a similar percentage of females (57.1%) diagnosed in the colonoscopy group (P = 0.8179) [Table 2].
The pattern of distribution of DD is shown in [Table 3] and was classified as left-sided [Figure 3], right-sided [Figure 4] or diffuse occurrence [Figure 2]. In both of the two studies, diffuse pattern was noted to be the highest (53.2%, colonoscopy and 56.8%, barium enema), followed by left-sided occurrence of DD (27.7%; colonoscopy vs. 29.7%; barium enema) and right-sided occurrence of DD (19.1%; colonoscopy method and 13.5%, barium enema).
[Table 4] shows the composite prevalence rates as reported by various workers for the years between 1978 and 2016. The reported figures of cases/years were annualized for comparison as shown in [Figure 1]. Very few cases of DD were reported in 1978 (14 cases in 3 years), but subsequent reports show a steady trend of increasing numbers, especially between 1994 and 2013 (5 cases/year), rising to 40 cases in 5 years. The two highest reported prevalence rates of the disease were those reported in the current study(DGMAH, Pretoria, South Africa) conducted in 2015 by two independent units: using colonoscopy (general surgery; 47 cases/year) and barium enema (radiology department, 37 cases/year) methods.
|Table 4: Other studies reporting on the incidence of diverticular disease in Africa|
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|Figure 1: Annualized occurrences of diverticular disease reported between 1978 and 2015 from different countries. A = Ghana; B = South Africa; C = Uganda; D = Nigeria; E and F = South Africa (present study)|
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| Discussion|| |
Both studies using barium enema and colonoscopy methods were carried out at this hospital(DGMAH, Ga-Rankuwa, Pretoria, South Africa) which serves predominantly black South Africans from the same catchment areas of Tshwane district in Gauteng, North–West and Limpopo provinces of South Africa. The mean ages obtained from the two methods, i.e. barium enema method (63 years) and colonoscopy method (67 years) are similar and are in agreement with results from previously reported findings in Africa.,,, The preponderance of females with DD was found in the present study (barium enema method, 62% and colonoscopy method, 58%). Although some other researchers have reported male predominance,, this finding agrees with some of the results found in black African population., Diffuse pattern of presentation of DD was found by the two methods: barium enema (57%) and colonoscopy (53%). The pattern of DD among black Africans found in this study is similar to the patterns previously published in the literature;,,, to some extent, it contradicts the previously reported cases of right-sided DD.,,, The main presenting symptom of the barium enema method was constipation (63.9%) while lower gastrointestinal bleeding (65.96%) was the main symptom found for the colonoscopy method.
Barium enema results of 166 patients were retrospectively reviewed for DD. Thirty-seven patients were positive (22.3%), while 129 patients (77.7%) were negative, giving a prevalence of 22.3%. Colonoscopy results of 384 patients were similarly reviewed for DD; 47 patients were found to be positive (13.50%) and 337 patients (86.50%) were found to be negative, with prevalence of 13.50%. Compared with barium enema, only half of the number of colonic diverticula can be detected by colonoscopy in the entire colon and even less on the left colon. DD is believed to be a disease of Western civilization; however, since the study of Keeley  from 1954 to 1956 to the present study, there hs been steady increase in the upward trend of DD in sub-Saharan Africa [Table 4] and [Figure 1].
Using two investigative modalities, namely barium enema and colonoscopy, two groups of independent researchers and departments at DGMAH, our studies corroborate each other and provide current evidence of the largest diagnostic yield of DD over a period of 1 year in Africa. The difference in the prevalence rates between the two procedures used for diagnosis in this study (13.5%, colonoscopy and 22.3%, barium enema) could have been as a result of the relative sensitivity of the methods of diagnosis. Nevertheless, the two methods being reported in this study, showing prevalence rates of 13.5% and 22.3%, represent positive upward trend in the occurrence of DD in Africa.
The highest prevalence of DD is reported to be found in the USA, Europe, and Australia, where up to 50% of the population over the age of 60 years and 60% of people over the age of 80 years have the disease., Until a few decades ago, it was believed that DD was rare in Africa due to adherence to the traditional African diet which is rich in fiber and may have been the preventive factor for the low prevalence among Africans.,
However, more recent findings revealed that this disease has shown an increase in prevalence in Africa., The reasons attributed to this rising incidence of the disease in Africa could have been due to DD being underdiagnosed previously where diagnostic facilities such as expertise and equipment were limited and inadequate. With better trained staff and the availability of state-of-the-art diagnostic equipment in the recent years in Africa, an increasing trend in the prevalence of the disease is bound to manifest. Another possible explanation of the increasing trend is the fact that aging and elderly population is on the increase in Africa, and since DD is a disease of the elderly, it is not surprising that there is now a tendency for an increase in the diagnostic yield of the disease.
Moreover, there is definitive higher rate of urbanization taking place in Africa and this is consequent on an increase in the migration of black African population from rural areas to economically developed suburbs and cities. The overall adverse effects of this continuous migration of people is the dramatic departure from the traditional African high-residue diet containing adequate fiber ( possible preventive factor for DD) to a low-residue diet, poor in dietary fiber, and can predispose to this disease.
| Conclusion|| |
The investigation of DD using barium enema method showed: female preponderance of DD, diffuse pattern of distribution, and mean age of 63.0 years (±15.6). These findings compare favorably with the investigation of DD carried out with colonoscopy method.
It is very important for radiologists, clinicians, and surgeons to understand the spectrum of imaging features of DD in order to enhance an early diagnosis of the disease, thus avoiding misdiagnosis which may even lead to loss of life.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Stollman N, Raskin JB. Diverticular disease of the colon. Lancet 2004;363:631-9.
Parks TG. Natural history of diverticular disease of the colon. Clin Gastroenterol 1975;4:53-69.
Painter NS, Burkitt DP. Diverticular disease of the colon: A deficiency disease of western civilization. Br Med J 1971;2:450-4.
Vally M, Koto MZ, Govender M. An investigation of diverticular disease among black patients undergoing colonoscopy at Dr. George Mukhari academic hospital, Pretoria, South Africa. S Afr Med J 2017;107:137-9.
Segal I, Walker AR. Diverticular disease in urban Africans in South Africa. Digestion 1982;24:42-6.
Baako BN. Diverticular disease of the colon in Accra, Ghana. Br J Surg 2001;88:1595.
Kiguli-Malwadde E, Kasozi H. Diverticular disease of the colon in Kampala, Uganda. Afr Health Sci 2002;2:29-32.
Alatise OI, Arigbabu AO, Lawal OO, Adetiloye VA, Agbakwuru EA, Ndububa DA, et al.
Presentation, distribution pattern, and management of diverticular disease in a Nigerian tertiary hospital. Niger J Clin Pract 2013;16:226-31. [Full text]
Madiba TE, Mokoena T. Pattern of diverticular disease among Africans. East Afr Med J 1994;71:644-6.
Mokoena T, Madiba TE. Haemorrhage – The main presenting feature of diverticular disease of the colon in blacks. S Afr Med J 1994;84:83-5.
Weizman AV, Nguyen GC. Diverticular disease: Epidemiology and management. Can J Gastroenterol 2011;25:385-9.
Keeley KJ. Alimentary disease in the Bantu: A review. Med Proc 1958;4:281-6.
Archampong EQ, Christian F, Badoe EA. Diverticular disease in an indigenous African community. Ann R Coll Surg Engl 1978;60:464-70.
Niikura R, Nagata N, Shimbo T, Akiyama J, Uemura N. Colonoscopy can miss diverticula of the left colon identified by barium enema. World J Gastroenterol 2013;19:2362-7.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4]